Elsevier

Urology

Volume 87, January 2016, Pages 88-94
Urology

Health Services Research
Understanding Inpatient Cost Variation in Kidney Transplantation: Implications for Payment Reforms

This manuscript was presented at the American Society of Transplant Surgeons Winter Meeting, Miami, Florida (January 2014) and at the American Urological Association meeting, Naples, Florida (May 2014).
https://doi.org/10.1016/j.urology.2015.05.037Get rights and content

Objective

To examine the magnitude and sources of inpatient cost variation for kidney transplantation.

Methods

We used the 2005-2009 Nationwide Inpatient Sample to identify patients who underwent kidney transplantation. We first calculated the patient-level cost of each transplantation admission and then aggregated costs to the hospital level. We fit hierarchical linear regression models to identify sources of cost variation and to estimate how much unexplained variation remained after adjusting for case-mix variables commonly found in administrative datasets.

Results

We identified 8866 living donor (LDRT) and 5589 deceased donor (DDRT) renal transplantations. We found that higher costs were associated with the presence of complications (LDRT, 14%; P <.001; DDRT, 24%; P <.001), plasmapheresis (LDRT, 27%; P <.001; DDRT, 27%; P <.001), dialysis (LDRT, 4%; P <.001), and prolonged length of stay (LDRT, 84%; P <.001; DDRT, 82%; P <.001). Even after case-mix adjustment, a considerable amount of unexplained cost variation remained between transplant centers (DDRT, 52%; LDRT, 66%).

Conclusion

Although significant inpatient cost variation is present across transplant centers, much of the cost variation for kidney transplantation is not explained by commonly used risk-adjustment variables in administrative datasets. These findings suggest that although there is an opportunity to achieve savings through payment reforms for kidney transplantation, policymakers should seek alternative sources of information (eg, clinical registry data) to delineate sources of warranted and unwarranted cost variation.

Section snippets

Dataset

Our primary dataset was the 2005-2009 Nationwide Inpatient Sample (NIS) linked to the American Hospital Association (AHA) annual survey. The NIS dataset is maintained by the Agency for Healthcare Research and Quality and is part of the Healthcare Cost and Utilization Project. For each year of the NIS, data on all discharges are available from a 20% sample of approximately 5000 hospitals in 44 states.

Cohort Identification

Using International Classification of Disease, Clinical Modification (ICD-9-CM) procedure codes,

Descriptive Analysis

From 2005 to 2009, 70,027 kidney transplants were performed in the United States. Of these transplants, 8866 DDRT and 5589 LDRT were included in our sample. At the patient level, the unadjusted cost of kidney transplant varied by donor type (DDRT median, $44,893; range, $15,674 to $533,097; LDRT median, $37,133; range, $15,544 to $312,986).

At the hospital level, inpatient costs varied approximately 4-fold for both DDRT and LDRT. The adjusted mean cost of DDRT was $39,843 (median, $39,740;

Comment

In this study, we found substantial variation in the THC for both LDRT and DDRT across transplant centers. Complications, the use of inpatient dialysis or plasmapheresis, length of stay, and high hospital volume were associated with higher costs. However, after adjusting for these and other patient and hospital characteristics, we found the majority of variation in total costs of inpatient kidney transplant care among hospitals still remained unexplained.

Unexplained cost variation may be the

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    Financial Disclosure: David C. Miller reports serving as a paid consultant for ArborMetrix. The remaining authors declare that they have no relevant financial interests.

    Funding Support: This research was supported by the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney (T32 DK 7782-14 to Chandy Ellimoottil).

    No funding organization played a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

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